Getting Started

First Name:

Last Name :

Address :

City :

State :           Zip:              Phone:

Email :

Please answer the follwing questions below.

Do you exercise regularly -or- are you physically active?

Do you have current illness, like a cold or respiratory inflammation?

Do you have any history of heart trouble?

Do you have, or have you recently had pain in your heart or chest?

Have you ever been told you have a joint or bone problem, like arthritis?

Do you have any family history of high blood pressure?

Do you have chronic back or neck problems?

Do you have any problems or pain with               
writs, knees, elbows, or shoulders?

Are you pregnant?

Have you had any major surgeries in the past year?

Are you over the age of 65 and not accustomed to physical exercise?

Do you have any physical or psychological conditions                       
which currently limit your day to day life?

Is there a physical or psychological reason why you must be                       
especially careful during an exercise program?

Is there a physical or psychological reason not mentioned                       
above why you should not begin this training?

NOTE:
If you answered"YES" to any of the above questions,
CONSULT WITH YOUR DOCTOR BEFORE INCREASING YOUR ACTIVITY LEVEL 
(find out, with medical evaluation from your doctor, whether your health will permit:
unrestricted physical activity, gradually increasing activity, or restricted activity for a period of time).

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Enter your initials in the box if you have answered the above questions honestly and accurately.
Enter your initials in the box: 
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WAIVER / RELEASE OF LIABILITY:******************************************************

By signing / initialling below, you agree that training and exercise, and especially Self-Defense, are strenuous in nature and, therefore potentially dangerous. You, the Client/Member, are aware that you are engaging in physical exercise and that the use of equipment, training, and instruction could cause injury, You are voluntarily participating in these activities and assume all risks of injury that may result. You agree to waive any and all claims or rights you may otherwise have to sue or otherwise bring action against Xcellent Solutions in Safety, LLC or any agent, associates, employees or instructors for injury to you as a result of these activities.  Furthermore, you also consent to you and your likeness, ie. photos and comments being used for marketing purpose of Xcellent Solutions LLC. You further agree that you have consulted your physician prior to beginning this exercise program and have been cleared by your doctor to participate.
Enter your initials in the box:

Once we have received your completed application, we will contact you by phone to review the information provided, as well as to discuss your wants, needs and limitations.  Scheduling may also occur at this time.